HomeMy Public PortalAboutAppointment of Campaign TreasurerAPPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
(PLEASE PRINT OR TYPE)
NOTE: This form must be on file with the qualifying
officer before opening the campaign account.
OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
Initial Filing of Form Re -filing to Change: tZ1 Treasurer/Deputy Depository D Office Party
2. Name of Candidate (in this order: First, Middle,
G�YaI n Nov) A cb
Last)
I both
3. Address (include post office box or street, city, state, zip
code)
O _p< I-132-0-
oriavtdo, 6 32W2
4. Telephone
( )
5. E-mail address
rahelrX,tdri mai1,�°"'
6.
Office sought (include district, circuit, group number)
fry applicable:C do c- "? CCU`► mi,5 iou.t2-, v(bIT'( 5
7. If a candidate for a nonpartisan office, check if
My intent is to run as a Write -In candidate.
8. If a candidate for a partisan office, check block and fill in name of party as applicable: My intent is to run as a
Write -In No Party Affiliation Party candidate.
9. I have appointed the following person to act as my Campaign Treasurer Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
Sa ) Gtcki
11. MailingAddress
I"L1 Ebi< 1461462
12. Telephone
( )
13. City
0r (coa a
14. County
Q<a J e.
15. State
F2-
16. Zip Code
32800-
17. E -ma I address
Eiraf1 e ikxdv 1 e g mail. cc►1'1
18. I have designated the following bank as my
a Primary Depository ❑ Secondary Depository
19. Name of Bank
,C' C:11P12AQ Y1 k.
20. Address
l 1 f 3. O a n5sa AV
U
21. City
OAavkc(o
22. County
0.(6v9C
23. State
Fl-
24. Zip Code
3 F
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND
DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE.
25. Date ``
Gl 7) -T
26. Signat re of Candidate
X P x4.ti
27. Treasurer's
I, (, _}e1(01(1
Acceptance of Appointment (fill in the blanks and check the appropriate block)
- bad4(I , do hereby accept the appointment
(Please Print or Type Name)
designated above as: Campaign Treasurer Deputy Treasurer.
1 X ck,°1/`
D te ,Si na re of Carip ign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.